目的:血清前白蛋白被认为是临床结局的敏感预测因子和营养支持的质量指标。然而,根据目前的指南,其对炎症的易感性限制了其在危重患者中的使用.我们评估了前白蛋白的初始值和动态变化的性能,以预测重症患者的ICU死亡率和营养支持的有效性。
方法:这项单中心研究包括2009年至2016年间入住ICU的患者,至少有一个初始前白蛋白值可用。从电子ICU图表中提取前瞻性记录的数据。我们使用单变量和多变量逻辑回归来估计前白蛋白预测ICU死亡率的性能。此外,通过多变量线性混合效应模型和多变量线性回归评估前白蛋白动态变化与营养支持之间的关联.进行亚组分析有助于确定前白蛋白动态评估具有特定相关性的患者。
结果:我们纳入了3136例患者,共有4942例前白蛋白水平。入住ICU时测得的前白蛋白(校正比值比(aOR)0.04,置信区间(CI)95%0.01-0.23)及其在第一周内的变化(aOR0.02,CI950.00-0.19)均与ICU死亡率呈负相关。在整个ICU住院期间,前白蛋白动态变化与累积能量(估计值:33.2,标准误差(SE)0.001,p<0.01)和蛋白质摄入量(1.39,SE0.001,p<0.01)相关。在逗留的第一周,前白蛋白变化与平均能量(6.03e-04,SE2.32e-04,p<0.01)和蛋白质摄入量(1.97e-02,SE5.91e-03,p<0.01)独立相关。值得注意的是,在老年或营养不良患者中,前白蛋白和能量摄入之间的关联最强,那些患有炎症增加和疾病严重程度高的人。最后,仅在SOFA<4的患者中,前白蛋白变化与第7天的平均氮平衡正相关(p=0.047).
结论:入住ICU时测得的前白蛋白及其在第一周的变化可作为ICU死亡率的准确预测指标。前白蛋白动态评估可能是评估ICU营养支持有效性的可靠工具。尤其是高危患者。
OBJECTIVE: Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients.
METHODS: This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance.
RESULTS: We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047).
CONCLUSIONS: Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.